Published: 2021-08-23

Post-tonsillectomy pain management in pediatric patients-a review

Santosh Kumar Swain


Tonsillectomy is a common surgical procedure performed in the pediatric age group. Although tonsillectomy is a safe surgery, it is associated with significant post-operative pain. Analgesia after tonsillectomy is often inadequate. Severe post-tonsillectomy throat pain has been described for more than a decade. Parents often worry for handling the pain of their children in home. Post-tonsillectomy pain is often considered as a long lasting and intense in nature. Post-tonsillectomy pain in children is an important problem which overstrains the patient, family and hospital staff. Post-tonsillectomy pain in children is an important problem which overstrains the patient, family and hospital staff. Regulatory alteration in the analgesic armamentarium, particularly in pediatric patients are making the treatment of post-tonsillectomy pain more difficult. Post-tonsillectomy pain in pediatric patients continues to be highly debated clinical issue and also an area of active research. Post-tonsillectomy pain can result in significant morbidity among pediatric patients. There are several analgesics available; each one has its own risk profile and unique side effects when used in pediatric age group in post-tonsillectomy period. This review article provides an update on recent management of post-tonsillectomy pain in pediatric patients. This article reviews the epidemiology, pathophysiology, impact of post-tonsillectomy pain in children and details of medications used for controlling post-tonsillectomy pain. 


Tonsillectomy, Post-tonsillectomy pain, Pediatric patients, Analgesics

Full Text:



Gehdoo R. Postoperative pain management in pediatric patients. Indian J Anaesth. 2004;48(5):406-14.

Scalford D, Flynn-Roth R, Howard D, Phillips E, Ryan E, Davis KF et al. Pain management of children aged 5 to 10 years after adenotonsillectomy. J Peri Anesthesia Nursing. 2013;28(6):353-60.

Sutters KA, Miaskowski C. Inadequate pain management and associated morbidity in children at home after tonsillectomy. J Pediatr Nurs. 1997;12(3):178-85.

Chaturvedi J, Vamanshankar H, Chandrashekar S, Manikantan K, Nayar RC. An assessment of postoperative pain in patients undergoing tonsillectomy. Otorinolaringologia. 2010;60(4):239-43.

Walco GA, Cassidy RC,Schechter NL. Pain, hurt, and harm: the ethics of pain control in infants and children. N Engl J Med. 1994;331:541-4.

Shinhar S, Scotch BM, Belenky W, Madgy D, Haupert M. Harmonic scalpel tonsillectomy versus hot electrocautery and cold dissection: an objective comparison. Ear Nose Throat J. 2004;83(10):712-5

Cullen KA, Hall MJ, Golosinsky A. Ambulatory surgery in the United States, 2006. Natl Health Stat Rep. 2009;11:1-28.

Swain SK, Sahu MC, Choudhury J, Ananda N. Adenotonsillectomy affecting quality of life in pediatric patients: Our experiences at a tertiary care teaching hospital of Eastern India. Ann Indian Academy Otorhinolaryngol Head Neck Sur. 2020;4(1):1-4.

Swain SK, Debta P, Sahoo S, Samal S, Sahu MC, Mohanty JN. An Unusual Cause of Throat Pain: A Case Report. Indian J Public Health Res Development. 2019;10(11):1029-31.

Swain SK, Jena A, Sahu MC, Banerjee A. Eagle's Syndrome: Our experiences in a tertiary care teaching hospital of Eastern India. J Head Neck Physicians Surg. 2017;5(2):66-70.

Swain SK, Choudhury J. Experience with the management of pediatric laryngopharyngeal reflux in an Indian teaching hospital. J Clin Sci. 2020;17(3):61-5.

Bhadoria P, Rathore P, Mandal S, Sehgal R, Meher R, Singh R. Role of Bupivacaine in reducing post tonsillectomy pain. Indian J Otolaryngol Head Neck Surg. 2006;58(4):335-6.

Swain SK, Das A, Nahak B, Behera IC. Microscope assisted coblation tonsillectomy: a safe and effective surgical technique. Int J Otorhinolaryngol Head Neck Surg. 2019;5(5):1446-50.

Sutters KA, Isaacson G. Post-tonsillectomy pain in children. Am J Nurs. 2014;114(2):36-42.

Isaacson G. Tonsillectomy healing. Ann Otol Rhinol Laryngol. 2012;121(10):645-9.

Swain SK, Ghosh TK, Munjal S, Mohanty JN. Microscope-assisted coblation tonsillectomy among paediatric patients–our experiences at an indian teaching hospital. Pediatria Polska-Polish J Paediatrics. 2019;94(3):170-4.

Hosseini Jahromi SA, Hosseini Valami SM, Naseh N. A comparison of the effect of oral paracetamol and clonidine on pediatric preoperative anxiety in adenotonsillectomy. Pak J Med Sci. 2009;25(3):458-61.

Swain SK, Debta P. Aspergillosis of the palatine tonsil. Ann Indian Academy Otorhinolaryngol Head Neck Surg. 2020;4(2):50-2.

Pierce CA, Voss B. Efficacy and safety of ibuprofen and acetaminophen in children and adults: a meta-analysis and qualitative review. Ann Pharmacother. 2010;44(3):489-506.

Merry AF, Edwards KE, Ahmad Z, Barber C, Mahadevan M, Frampton C. Randomized comparison between the combination of acetaminophen and ibuprofen and each constituent alone for analgesia following tonsillectomy in children. Can J Anaesth. 2013;60(12):1180-89.

Martin SD, John LD. Implications of a Retrospective Study on Weight-Based Risk for Post-Tonsillectomy Pain in Children. J Peri Anesthesia Nursing. 2020;35(2):140-6.

Swain SK, Anand N, Sahu MC. Peripheral facial nerve palsy-A rare complication of tonsillectomy. Ann Indian Academy Otorhinolaryngol Head Neck Surg. 2020;4(1):10-2.

Salonen A, Kokki H, Nuutinen J. Recovery after tonsillectomy in adults: a three-week follow-up study. Laryngoscope. 2002;112(1):94-8.

Gallagher TQ, Wilcox L, Mcguire E, Derkay CS. Analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: comparing three tonsillectomy techniques. Otolaryngol Head Neck Surg. 2013;142(6):886-92.

Riggin L, Ramakrishna J, Sommer DD, Koren G. A updated systematic review and meta-analysis of 36 randomized controlled trials; no apparent effects of non-steroidal anti-inflammatory agents on the risk of bleeding after tonsillectomy. Clin Otolaryngol. 2013;38(2):115-29.

Bean-Lijewski JD, Kruitbosch SH, Hutchinson L, Browne B. Post-tonsillectomy pain management in children: can we do better? Otolaryngol Head Neck Surg. 2007;137(4):545-51.

Tawalbeh MI, Nawasreh OO, Husban AM. Comparative study of diclofenac sodium and paracetamol for treatment of pain after adenotonsillectomy in children. Saudi Med J. 2001;22(2):121-3.

Kongara K, Chambers JP, Johnson CB. Effects of tramadol, morphine or their combination in dogs undergoing ovariohysterectomy on peri-operative electroencephalographic responses and post-operative pain. New Zealand Veterinary J. 2012;60(2):129-35.

Akbay BK, Yildizbas S, Guclu E, Yilmaz S, Iskender A, Ozturk O. Analgesic efficacy of topical tramadol in the control of postoperative pain in children after tonsillectomy. J Anesth. 2010;24(5):705-8

Steward DL, Grisel J, Meinzen-Derr J. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev. 2011(8):CD003997.

Park SK, Kim J, Kim JM, Yeon JY, Shim WS, Lee DW. Effects of oral prednisolone on recovery after tonsillectomy. Laryngoscope. 2015;125(1):111-7.

Bellis JR, Pirmohamed M, Nunn AJ, Loke YK, De S, Golder S et al. Dexamethasone and haemorrhage risk in paediatric tonsillectomy: a systematic review and meta-analysis. Bri j anaesthesia. 2014;113(1):23-42.

Suzuki S, Yasunaga H, Matsui H, Horiguchi H, Fushimi K, Yamasoba T. Impact of systemic steroids on post tonsillectomy bleeding: analysis of 61 430 patients using a national inpatient database in Japan. JAMA Otolaryngol-Head Neck Surg. 2014;140(10): 906-10.

Jahromi SA, Valami SM, Hatamian S. Comparison between effect of lidocaine, morphine and ketamine spray on post-tonsillectomy pain in children. Anesthesiol pain med. 2012;2(1):17-21.

Özkırış M, Mutlu C. The effects of post-operative topical chlorhexidine gluconate and benzydamine HCL spray (farhex) on postoperative pain and oral intake in tonsillectomied patients. J Med Med Sci. 2011;2(10):1143-6.

Demster JH. Post-tonsillectomy analgesia: The use of Benzocaine Lozenges. J Laryngol Otol. 1988;102:813-4.

Nunez DA, Provan J, Crawford M. Postoperative tonsillectomy pain in pediatric patients: electrocautery (hot) vs cold dissection and snare tonsillectomy-a randomized trial. Arch Otolaryngol Head Neck Surg. 2000;126:837-41.

Akoglu E, Akkurt BC, Inanoglu K, Okuyucu S, Dagli S. Ropivacaine compared to bupivacaine for post-tonsillectomy pain relief in children: a randomized controlled study. Int J Pediatr Otorhinolaryngol. 2006;70:1169-73.

Nikandish R, Maghsoodi B, Khademi S, Motazedian S, Kaboodkhani R. Peritonsillar infiltration with bupivacaine and pethidine for relief of post-tonsillectomy pain: a randomised double-blind study. Anaesthesia. 2008;63:20-5.

Giannoni C, White S, Enneking FK, Morey T. Ropivacaine with or without clonidine improves pediatric tonsillectomy pain. Arch Otolaryngol Head Neck Surg. 2001;127:1265-70.

O’Flaherty JE,Lin CX. Does ketamine or magnesium affect posttonsillectomy pain in children? Paediatr Anaesth. 2003;13:413-7.

Tverskoy M, Oren M, Vaskovich M, Dashkovsky I, Kisin I. Ketamine enhances local anesthetic and analgesic effects of bupivacaine by peripheral mechanism: a study in postoperative patients. Neurosci Lett. 1996;215:5-8.

Freeman SB, Markwell JK. Sucralfate in alleviating post‐tonsillectomy pain. Laryngoscope. 1992;102(11):1242-6.

Boroumand P, Zamani MM, Saeedi M, Rouhbakhshfar O, Hosseini Motlagh SR, Aarabi Moghaddam F. Post tonsillectomy pain: can honey reduce the analgesic requirements? Anesth Pain Med. 2013;3(1):198-202.

Benhanifia B, Boukraa L, Hammoudi M, Sulaiman A, Manivannan L. Recent Patents on Topical Application of Honey in Wound and Burn Management. Recent Patents Inflamm Allergy Drug Discov. 2011;5(1):81-6.

Al-Waili N, Salom K, Al-Ghamdi AA. Honey for wound healing, ulcers, and burns; data supporting its use in clinical practice. Sci World J. 2011;11:766-87.

Kelly LE, Sommer DD, Ramakrishna J, Hoffbauer S, Arbab-Tafti S, Reid D et al. Morphine or Ibuprofen for post-tonsillectomy analgesia: a randomized trial. Pediatrics. 2015;135(2):307-13.

Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol head neck surg. 2011;144(1):1-30.

Swain SK, Ghosh TK, Das A. Microscope-Assisted coblation tonsillectomy: Our experiences at a tertiary care teaching hospital of eastern India. Ann Indian Academy Otorhinolaryngol Head Neck Surg. 2020;4(2):35-8.